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2005 The New England Center for Children, Inc. (NECC); All Rights Reserved; No portion of this work is to be reproduced or distributed without the express written permission of NECC.
Understanding and Addressing
Feeding Problems of Children with
Autism
William H. Ahearn
Ph.D., BCBA-D, LABA
Overview
Fdg prbs in ASDs vs DD/TDC Are there special concerns? Y/N
Issues related to Autism Tx and Fdg
Food selectivity in ASDs
Is it a problem?
When it is what do (can) you do?
Exposure!
Vomiting
Refusal; Expulsion; Vomiting
And case examples
2
Kids who didn’t eat vegetables
Matt
- 4
- Moderately selective
- Ate chicken nuggets and other breaded proteins, no fruit/veg
Dave
- 3.5
- Mildly selective
- Ate chicken nuggets, some bread, turkey, some fruit, no veg
Txs tried and outcomes
Matt
- Introduced new brands of old items
- Reinforced eating with TV access
- Ate peas, corn, green peppers, carrots within 2 months
Dave
- Introduced new brands/items
- Reinforced eating with preferred videos
- Restricted access to preferred videos, blocked disruptive behavior
- 9 months before first veggie eaten
3
Follow-up
Matt (mild dev. delays)
- TV access moved to end of meal
- Started eating salad (modeled by mom)
- Also ate a variety of fruits (req. apple)
Dave (Autism)
- 3 months after 1st veg (was eating 3) got sick refused veg when better
- 2 months later veg was recovered
- Video access signaled on token board
- Eats 3 fruits with prompting
Kids who didn’t eat
Robert (TDC)
- 4 (on initial evaluation)
- Total food refusal
- Severe GI involvement, OM deficits
Bob (CWA)
- 3.5 (on intake)
- Total food refusal
- History of eating (bottles), gagging/vomiting w/ ear infections
4
Txs tried and outcomes
Robert (following medical TX)
- Introduced rewards for accepting ES
- Gradually introduced pureed foods
- Required escape prevention (3 times; 1 x per caregiver)
- Taught OM skills (lateral placement; modeling)
- Volume limited intake (no more than 4 oz)
Bob (following ear tube placement)
- Introduced formula on spoon
- Gradually introduced pureed foods
- Introduced rewards for swallowing
- OM skills emerged; regular foods in 6 mo.
Empty Spoon: Instructional
Fading with Shaping
In the absence of eating/drinking behavior
Establishing appropriate behavior
Problem behavior/resistance/anxiety
Empty Spoon
To reinforce or not reinforce
Establishing positive history
Gradually introduce tastes
Gradually increase amount on spoon
Transfer of stimulus control
5
Empty Spoon: Instructional
Fading with Shaping
Tastes
Juice, formula, milk, preferred
Avoid bitter or chewy at beginning
Gradual changes
Shaken (not stirred)
Drop covered ¼ ½ ¾ full
Gradually introduce variety
Gradually increase texture
Problem behavior emerges back up
Feeding behavior
Acceptance
Self-feeding/non self-feeding
Open mouth
Refusal
Expulsion
Swallowing
Chewing
6
Why is feeding of particular
concern to parents of children
with ASD/DD? Awareness of health risk with ASDs/DD
Related conditions
Problems in typical development
Resistance to change (Kanner, 1943)
Fdg skills develop as each child ages
Transitions (Stevenson & Allare, 1991)
Liquid Solid
Pureed Textured
Typical child prblms during transition
Do children with autism have
aberrant eating habits? Ahearn et al. (2001); 50%+ selective
>25% overly selective (1 food grp)
70% for starches
Remove gluten from diet?
Parents report more Fdg prb
Schreck, Williams, and Smith (2004)
Narrower range, family diet child diet
Schreck and Williams (2006)
Children w/ASDs may eat more than TDCs
(Raiten & Massaro, 1986)
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Treating ASDs via Diet?
Diet and behavior
Feingold was wrong
Hoover & Milich (1994); words over sugar
GFCF diet
Anecdotal report (e.g., Cade et al., 2000)
Elder et al. (2006)
Data to determine effects
Ketogenic diet
Evangeliou et al. (2003); intractable seizures
Treating the gut?
Gut Txs of ASD No change in autism
Diets as Tx For true allergy/intolerance
Vitamins as Tx
1995 NIMH Subcommittee
Lawson et al. (2007); Overuse & prostate
cancer
Secretin (e.g., Roberts et al., 2001)
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What is a feeding problem?
Refusal Selectivity
Ahearn (2001)
Most critical function
of eating
Caloric intake
Growth and weight gain
What is a feeding problem?
Refusal Selectivity
Ahearn (2001)
The role of early history
TFR = good reason to not want to eat
Selectivity = decline in diet or static?
Food and texture selectivity
Early identification = hi prob. Success
Texture selectivity/caloric intake/oral motor skills
Variables associated w/ difficult fdg problems
GI symptoms Pediatric Gastroenterologist
OM SPL
9
Questions
Assessment of eating
Functional assessment?
Evaluate physical status
Weight/growth/output
GI functioning
Evaluate intake through observation
Food logs (Ahearn, 2001)
In vivo assessment (Munk & Repp, 1994)
Expert multi-disciplinary assessment
(e.g., Kedesdy & Budd, 1998)
10
Direct Assessment – Food Log
Diet history
Sample of presentation and intake
Across day
No changes to mealtime, etc.
Observation in natural
environment
Assessing behavioral dynamics
Attention/Escape/Esc + access to
SR+
11
Diet History - Summary
Categorizing eating patterns
Overly & moderately selective
Mildly selective
Food refusal (chronic vs acute)
Problems of limited exposure
Other limitations
Outcome of observation
Rule out physiological factors
Identify skill deficits
Decide whether they are important
ID problems in the eating
environment
Establish goals
12
Selective eating
Categories (Ahearn et al., 2001)
- Overly/severely
- Moderately
- Mildly
- Texture selective
Develops why? (Piazza et al., 2003)
- Escape from NP
- Attention (?)
- Tangibles (Escape to other food)
Consequences &
Presentation Timing of food presentation
Grazing/Access to food outside of
meals
Motivational operations
Exposure to foods
Birch & Marlin (1982)
13
Selective Eating
Develops when? (Carruth et al., 2004)
- As many as 50% of all toddlers
- Selectivity increases w/ age
- Typically meet nutritional requirements
Transient? (Carruth & Skinner, 2000)
- Severe traced to early eating history
(Marchi & Cohen, 1990)
Structuring mealtimes
Existing structure to meals
Meal as routine
Altering structure
Eating environment
Timing of access to food
Discrete trial format
Which items are presented
How to present them
Routines with items/plate
From structure to exposure
14
What to do first
Diet record summary
Select foods for exposure
- Half of foods should be preferred
- 1-3 target (new) items for each
group
- At least 1 item from each food
group
- Don’t choose bitter or smelly foods
Procedures
Exposure program
- 18 sessions (1 block)
- Target item presented 6 times per
block
- Self-feeder presentation
- No differential consequences
- About 30 minutes before meal
15
Procedures
Meals (session)
- 2 accepted + 2 target items
- 5 presentations of each item
- Order of presentation quasi-randomized
- Single-item on plate
- “(Child’s name), take a bite”
- 5-10 s to consume
- Refusal = neutral removal
- 30 s ITI
Picky Eaters
Mike
- 4, ASD
- Moderately selective
- Preferred starch, limited pro, no fruit/veg
Chris
- 2.5, ASD
- Mildly selective
- Preferred starch, limited pro/veg/fruit
- Gagging/vomiting
16
0
2
4
6
8
10
Sessions
Nu
mb
er
of
Ta
rge
t B
ite
s A
cc
ep
ted
First Block of Exposure Sessions
Mike
0
2
4
6
8
10
0 2 4 6 8 10 12 14 16 18
0
2
4
6
8
10
Second Block of Exposure Sessions
Third Block of Exposure Sessions
p(present)p(accept)
p(present.)p(accept.)
Dail
y P
rob
ab
ilit
y
0.00
0.25
0.50
0.75
1.00 Fruit
Vegetable
Starch
Mike
Protein
Pre-exposure Post-exposure
17
0
2
4
6
8
10
ChrisSessions
Nu
mb
er
of
Targ
et
Bit
es
First Block of Exposure Sessions
0 2 4 6 8 10 12 14 16 18
0
2
4
6
8
10
Accept
Gagging
p(present)p(accept)
p(present.)p(accept.)
Dail
y P
rob
ab
ilit
y
0.00
0.25
0.50
0.75
1.00 Fruit
Vegetable
Starch
Chris
Protein
Pre-exposure Post-exposure
18
Results & Discussion
Exposure = improved intake
- All consumed target items
- Results generalized to meals
Selectivity shaped
- Consistent presentation of variety
- Exposure sessions like DTT
Limited to mild feeding problems
- Novel foods in assessment
Questions?
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Quick Review of Treatments Medical intervention
Altering the feeding environment
Mealtime structure and food exposure
Simultaneous presentation
Food blending + fading
Arranging new consequences
Pos. reinf. (Kedesdy et al., ‘98)
Escape prevention (Ahearn et al., 1996)
Teaching
Texture fading (Shore et al., 1998)
Task analysis (Luiselli, 1993)
Positive Reinforcement
Access to preferred foods??? (Riordan et
al., 1980)
Access to activities/attention (Kerwin et
al., 1995)
Using highly preferred items
Motivated to earn/limited access at other
times
Assessment (Fisher et al., 1992)
Reinforce each accepted bite immediately
20
Example - Larry
4 year old boy diagnosed with autism
Eating at meals good but variety
decreasing
Accepted a variety of starches/proteins Limited intake of fruits/vegetables
Goal - Increase acceptance of Fruit/Veg Starting point - Fruit
Feeding Sessions
Baseline -15 presentations of fruit
5 each
Most preferred item was video 30 seconds of “Barney” for acceptance
Data recorded on Accepts/Expel
15 total bites presented during
treatment
Target Item Beginning of session
3 bites added after eating criteria met
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Session
0 2 4 6 8 10 12 14 16 18 20 22 24
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22 24
0
20
40
60
80
100
Apple
0 2 4 6 8 10 12 14 16 18 20 22 24
Perc
en
tag
e o
f A
ccep
tan
ce
0
20
40
60
80
100
Banana
Peach
BASELINE 30" ACCESS TO VIDEO
3 bites
Larry
= Added bites at that meal
6 bites
9 bites
3 bites
6 bites
9 bites
3 bites
6 bites9 bites
Simultaneous presentation
Sequential presentation (as SR+)
(Riordan et al., 1980; 1984)
Simultaneous presentation
(Kern & Marder, 1996)
Sim. Presentation w/out EP (SR+)
(Piazza et al., 2002)
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Simultaneous presentation
w/out SR+
Fred ate no vegetables (Ahearn et al., 2001)
Ate a variety of starches, proteins,
condiments
PS preference assessment
- Ketchup, BBQ sauce, salad dressing
Multiple baseline design across V
- Withdrawal to BL btw condiments
Simultaneous presentation
w/out SR+
5 consecutive presentations of
each
BL – no differential consequences
SP – food + 5cc of condiment
Each condiment introduced in MB
23
Session
0 5 10 15 20 25 30 35 40
0
20
40
60
80
100Per
cen
tag
e o
f B
ites
Acc
epte
d
0
20
40
60
80
100
0
20
40
60
80
100
Carrot
Broccoli
Corn
BLSimultaneous
Presentation BL BLSimultaneous
Presentation
Simultaneous
Presentation
Simultaneous presentation
and fading
Transfer of stimulus control
Texture fading (Shore et al., 1998)
Probes and “errorless”
Blending preferred and
nonpreffered Low concentration of NP
24
Simultaneous presentation
and fading
Phil - selective and ate few
proteins
Consumed variety of fruits Inconsistent acceptance
Targeted fruits and chicken 5 nonconsecutive bites of each item
Differential reinforcement Acceptance resulted in activity access
Refusal resulted in neutral removal
Session
0
20
40
60
80
100Per
cen
tage
of
Bit
es A
ccep
ted
0
20
40
60
80
100
0
20
40
60
80
100
Banana
Grape
BL SR+ for acceptance
Chicken
25
Simultaneous presentation
and fading
Accepted age-appropriate texture
Decreased texture of banana to puree About ¾ of spoonful
Mixed in a small amount of chicken
Gradually increased amount of NP Concomitant decrease in banana
Increased texture of chicken back to small bite sized pieces
Session
0 5 10 15 20 25 30 35
0
20
40
60
80
100
BL SR+ for acceptance
Per
cen
tag
e o
f B
ites
Acc
epte
d
BL Simultaneous Presentation + Fading
Increase amount
of chicken
All chicken
puree Decrease amount
of water in puree
Ground
chicken
Bite-sized
chicken
26
Escape prevention
Consumption of food required to end
meal
Professional supervision necessary
Nonremoval of the spoon (Ahearn et al., 1996; Cooper et al., 1995)
Physical guidance
(Ahearn et al., 1996; Riordan et al., 1980)
Example - Paul
4 year old boy diagnosed with
autism
Overly selective
Quit eating solid food during illness
Previously ate grilled cheese and
pancakes
Accepted no food for 4 weeks
Goal - Increase acceptance Starting point – Foods previously consumed
27
Physical Guidance
Parent selected intervention
Conducted at school
Two therapists for each meal
SR+ food acceptance – HP items
Refusal – prompt at jaw
4 total prompts prior to Ind. ACC
New food at 7th meal
12 foods IA in 39 meals
3 months from no solids to feeding himself at home without physical prompting
0
20
40
60
80
100
ALTERNATING TREATMENTS
PE
RC
EN
T A
CC
EP
TA
NC
E
0
20
40
60
80
100
SESSION
0 15 30 45 60 75
0
20
40
60
80
100
PHYSICAL GUIDANCEDIFFERENTIAL W/DRWL
Figure 1.
SR+ OF
ACCEPTANCE
GUIDANCE (PG)
PHYSICAL
OF SPOON (NS)
NONREMOVAL
SR+
SR+
PG PG
OF NS
DONNA
PAM
CALVIN
28
0
20
40
60
80
100
PE
RC
EN
T C
OR
OL
LA
RY
BE
HA
VIO
R
0
20
40
60
80
100
SESSION
0 15 30 45 60 75
0
20
40
60
80
100
CALVIN
PAM
DONNA
Figure 4.
ALTERNATING TREATMENTS PHYSICAL GUIDANCEDIFFERENTIAL W/DRWLSR+ OF
ACCEPTANCE
OF NS
Comparing NR and PG
Both very effective
Acceptance may be more rapid with PG
Side effects
In NR Meals longer - more time=more side effects
PG sometimes suppresses other aberrant behavior
Treatment acceptability
29
Gagging and Vomiting
Why do children gag?
Novel textures (Texture sensitivity?)
Lack of oral competence (elicitation)
Illness
To avoid consuming NP foods
What can be done?
Do not provide undue attention/escape
Teach oral skills/repeated exposure
Access to preferred liquids
Escape prevention???
Example - Matt
5 year old boy diagnosed with autism
Eating at meals good but
gagged/vomited 4-5x/week
Accepted a variety of
starches/proteins
Limited intake of fruits/vegetables
Goal – Decrease vomiting
Starting point – Assessing cause
30
Session
0 2 4 6 8 10 12 14 16 18 20
Ra
te p
er
Min
ute
- G
ag
gin
g
0.0
0.2
0.4
0.6
Legend
Matt
Rotate novel foods after each block of conditions
Escape
Attention
Esc to Known
Control
All gags on vegetables
Exposure
During assessment
Gags on veggies (mostly greens)
Gags during first 1-2 presentations
Exposed to foods that led to gags
Consecutive presentations of NP/P
No attention (lined garbage can)
Later presented novel foods/scents
31
0.0
0.2
0.4
0.6
0.8
Pro
bab
ilit
y o
f g
ag
gin
g/f
irst
pre
sen
tati
on
0.0
0.2
0.4
0.6
0.8
0.0
0.2
0.4
0.6
0.8
Green Veg
Other Veg
Veg w/garlic+oil
Pre Post Pre Post Pre Post
Pre Post Pre Post Pre Post
Pre Post Pre Post Pre Post
Expulsion
Lacking OM skills
Texture fading lumps
Lateral placement (on molars)
Modeling
Escape prevention
Re-presentation (standard in PG/NR)
Flipped spoon/nuk brush (Piazza and
colleagues, 2011)
32
Closing comments
Prevention of the development of selective feeding for children with autism
Early intervention
Availability and accessibility of resources
Gut theory of autism Measles insults the gut causing bowel
dysfunction which then results in regression
Wakefield et al. (1998) – RETRACTED
GMC hearing
Gut-theory of autism: Empirical evidence against
MMR (e.g., Madsen et al., 2002)
MMR/Bowel (Taylor et al., 2002)
GI/Autism (Black, Kaye, & Jick, 2002)
Mayo clinic (Ibrahim et al., 2009)
Buie et al. (2010)
33
D’Souza, Fombonne et al.
(2006)
Presence of measles in gut/blood/tissue
Detected by polymerase chain reaction
assays
Used same techniques as others
Larger N
Used improved contaminant control
No measles virus found in control or ASDs
Stephen Bustin/Nicholas Chadwick OAP
Number of deaths last
year = over 200,00
Millions maimed – blind,
deaf, scarring
US – prevaccine 3-4 M
cases/yr; 1 in 250 died;
50k hospital; 1000
permanently disabled
Post 1997 usually fewer
than 100/yr, until 2008+
34
Eating patterns of children
w/ASD
30 children diagnosed w/ Autism/PDD-
NOS (Ahearn et al., 2001)
Ranging in age from 3y 9m to 14y 2m
Survey of eating habits
6 meals for each child
24 presentations per session
4 food groups
3 items per group
2 textures
Participant 13
FRUIT
VEGE
PROT
STA
R
0
5
10
15
20
25
30
Participant 11
FRUIT
VEGE
PROT
STA
R
0
5
10
15
20
25
30Participant 18
FRUIT
VEGE
PROT
STA
R
0
5
10
15
20
25
30
Participant 25
FRUIT
VEGE
PROT
STA
R
0
5
10
15
20
25
30
All accepts pureed except3 bites of banana
Food Type
Participant 12
FRUIT
VEGE
PROT
STA
R
0
5
10
15
20
25
30Participant 22
FRUIT
VEGE
PROT
STA
R# o
f B
ites A
ccep
ted
0
5
10
15
20
25
30
Food Type
35
Questions?